The Current Landscape of Substance Use in the U.S.

Overdose rates in the United States have reached alarming levels in recent years, fueled primarily by opioids, including both prescription pain medications and illicit drugs like heroin and fentanyl. The crisis has led to a significant increase in overdose deaths, with over 100,000 fatalities recorded annually in recent years. This epidemic has not only affected individuals and families but has also placed a tremendous burden on public health systems and communities across the country. Public health initiatives aimed at prevention, treatment, and harm reduction are a critical part of the solution to reducing overdose deaths.

In recognition of National Overdose Awareness Day, Brendan Saloner, Bloomberg Professor of American Health in the Department of Health Policy and Management, spoke with the Initiative about the current landscape of substance use in the United States and what policies have been, or could be, successful in saving lives across the country:

1. How has the landscape of substance use and overdose risk changed in recent years?

From 2016 to 2021, opioid-involved overdose deaths nearly doubled, from 42,249 to 80,411 with people of color and young people seeing the most significant increase. While the pandemic certainly led to more solitary drug use and new stresses, the big change we have seen in the last few years is the rapid expansion of illicitly manufactured fentanyl across the country and into the drug supply of stimulants like cocaine. This has also changed the profile of people who overdose, especially with more polydrug overdose deaths, deaths that involve two or more substances, and rising deaths among Black and Native American individuals.

2. Can you briefly explain what medication for opioid use disorder is and the role it plays in overdose prevention?

Medications for opioid use disorder refers to the use of FDA-approved medications, like methadone, buprenorphine, and naltrexone that can help manage the core symptoms of opioid use disorder. Medications like buprenorphine and methadone in particular have been shown to cut the risk of overdose in half. They work by reducing cravings, stabilizing the physiological changes that often occur in people with substance use disorders, and decreasing the withdrawal that happens when people stop using opioid drugs like fentanyl.

3. How can access to these medications be improved?

We are seeing big increases in the number of people receiving medication treatment, but there are still some very significant barriers to getting treatment including the issues of getting insurance to promptly pay, finding a clinician who will prescribe buprenorphine, or navigating the complex system around methadone clinics. As part of the omnibus bill, the Substance Abuse and Mental Health Services Administration removed the federal requirement for practitioners to maintain a special license to prescribe buprenorphine for the treatment of opioid use disorder which is one step in the right direction. The key policy strategy at this point needs to focus on boosting the capacity of prescribers to treat new patients, especially in settings where people may be in crisis.

4. What policies have been most successful in reducing overdose deaths?

The combination of low-threshold medication treatment, broad naloxone distribution in the community, and tools to help people use more safely like fentanyl test strips and sterile syringes are all very helpful. Other countries also have more access to overdose prevention centers, which could really help by giving people a safe, supervised place to use. Last year I visited Portugal, where I had a chance to see firsthand the importance of programs like mobile methadone and safe consumption sites on the lives of people who use drugs.

5. How can data collection on overdoses be improved to better inform prevention efforts?

We need to know more about how often people who need help the most are able to access services, and why there are "voltage drops" in the system. I would like to see more data collection that follows people who have experienced a high-risk event such as a nonfatal overdose or release from jail to see how they are navigating services.

6. What are some areas for potential improvement in opioid-related policies?

The challenge is designing policies that get more of the effective interventions to more people. We need to look at strong incentives to get medication treatment to be the standard of care across all settings. It is not enough to get the right intervention to a few people, the effective treatments need to be available to everyone who could benefit to get public health impact. In short, policies should be as obsessed with scale as I am!